
    <div class="container-fluid">
      <div class="row-fluid container_bg">
       <div ng-include="'side-menu.html'"></div>
        <div class="span9 pos_r" style="padding-right:20px;">
			<div class="container_title" >
				<div class=""><h1>Send Service Tests</h1><a href="#/services-history" style="position:absolute;top:29px;right:10px;">History</a>
				</div>
				<div  id="success_alert" class="alert_sucess alert alert-success span11" style="display:none;">
					<i class="icon-ok"></i>&nbsp;&nbsp;
					<span>{{ successcDiv }}</span>
				</div>
				<form class="form-horizontal" id="servicess" name="servicess" ng-submit="requestServiceValidations(servicess)" >
					<div>Select Services : <select ng-model="choice" id="Testname" name="Testname[]" multiple="multiple" ng-change="dispalySelectedValues()" ng-bind-html="services" >
					</select><span style="color:red">{{ errorname }}</span></div><br/>
					<div id="selectedtests"  >
					</div>
					<p ng-show="hidtototalamount">Total Amount:<input type="text" id="totalamount" name="totalamount" ></p>
					<div>Do You Have Insurence:
					<input type="radio" name="insurenceyes" id="insurenceyes" value="1" ng-click="InsurenceFun(1)" ng-model="ser.insurenceyes" ng-required="!insurenceyes" >YES
					<input type="radio" name="insurenceyes" id="insurenceno" value="0" ng-click="InsurenceFun(0)" ng-model="ser.insurenceyes" ng-required="!insurenceyes" >NO
					<span id="insurenceyesError" name="insurenceyesError" style="color:red">
					</div><br/>
					
					<div style="display:none" id="insurenceHide" >
					Insurance : <select ng-modal="insoption" id="insurance" name="insurance" ng-model="s.insurence" ng-change="SelectInsurenceFun()" ng-bind-html="optionInsurence"></select>
					</div><br/><br/><br/>
					
					<div style="display:none"  id="nursing_policies" >
					policy number:<input type="text" id="pnumber" name="pnumber"  required ><br/><br/>
					Policy Hoder Name:<input type="text" id="policyhname" name="policyhname" required ><br/><br/>
					UST Dependent:<input type="text" id="dependent" name="dependent" required ><br/><br/>
					</div>
					<div style="margin-left:400px; margin-top:-50px; "><input type="checkbox" ng-model="checkboxModel.value1" name="checkbox" id="checkbox" ng-click="changeuserAddress()" />Change Address</div><br/>
					
					<p style="color:red">UserAddress:</p>
					<div ng-bind-html="userinfo">
					</div>
					<div class="control-group">
						<div class="controls">
							<button  class="medicart_btn" >Send</button><span ng-bind-html="requestServiceReload"></span>
						</div>
					</div>
					<p id="hiddentype" ng-show="hiddentype" ><input type="text" id="type" name="type" value="0" ng-model="ser.type"  ng-init="ser.type='0'" ></p>
				</form>
				</div>
			</div>
        </div>
      </div>
    </div>
	

	
	